Participatory economic approaches in global health evaluations
Authors: Meghan Bruce Kumar, Sanam Roder-DeWan, Alinane Linda Nyondo-Mipando, Tolib Mirzoev, Cicely Marston
Journal: The Lancet Global Health (2023)

Health interventions are inherently complex and demand commensurate sophisticated evaluation approaches. Economic evaluations assess costs and consequences of alternative interventions. Participatory approaches might engage those affected by an intervention in designing, assessing, or improving it. We call for integrating participatory approaches with economics in global health evaluation. This integration would underpin holistic, context-specific, people-centred, and policy-relevant evidence in global health. Integrating participatory and economic evaluation approaches will address some limitations of current practice in global health. First, integrated approaches will make explicit the economic considerations in patient treatment adherence, centring service users. To drive equity, patient-centred, high-quality health care, and dignity-based practice, people should be equal participants in the evaluation of the interventions.1Abimbola S When dignity meets evidence.Lancet. 2023; 401: 340-341Summary Full Text Full Text PDF Google Scholar Behavioural interventions must account for costs and consequences for individuals, families, and communities. Key modifications to improve the sustainability of an intervention might not be costly, but might be essential to individuals, especially when driven by economic or person-time costs to users. For example, examining low uptake of antenatal care in Kenya with community quality improvement teams showed that long waiting times detered users due to opportunity costs, thereby delaying antenatal care presentation, which in turn caused health problems.2USAID SQALESharing knowledge and experience on quality improvement for community health and sustaining change: USAID SQALE Learning Event Report.http://usaidsqale.reachoutconsortium.org/publications-and-tools/sharing-knowledge-quality-improvement-community-health-sustaining-change/Date: 2019Date accessed: June 7, 2023Google Scholar A participatory economic evaluation that explicitly surfaces the time costs to users and their implications to the users rather than assuming a flat opportunity cost of time, alongside health consequences of adherence and non-adherence, would be an ideal evaluation. Second, these approaches will generate context-specific and applied evaluation outputs. This would help meet demand from policymakers for locally relevant evidence that captures both resources and mechanisms,3Witter S Anderson I Annear P et al.What, why and how do health systems learn from one another? Insights from eight low- and middle-income country case studies.Heal Res Policy Syst. 2019; 17: 9Crossref PubMed Scopus (0) Google Scholar, 4Fadlallah R El-Jardali F Nomier M et al.Using narratives to impact health policy-making: a systematic review.Heal Res Policy Syst. 2019; 17: 26Crossref PubMed Scopus (33) Google Scholar, 5Uzochukwu B Onyedinma C Okeke C et al.What makes advocacy work? Stakeholders' voices and insights from prioritisation of maternal and child health programme in Nigeria.BMC Health Serv Res. 2020; 20: 884Crossref PubMed Scopus (3) Google Scholar, 6Kumar MB Taegtmeyer M Madan J et al.How do decision-makers use evidence in community health policy and financing decisions? A qualitative study and conceptual framework in four African countries.Health Policy Plan. 2020; 35: 799-809Crossref PubMed Scopus (10) Google Scholar and would centre the service user within a network of decision makers. The decision maker drives the choices of costs and outcomes to include in-economic evaluations, and participatory methods can help evaluators assess the effect of decisions to the particular individuals and communities in a given context and decision space. Similarly, the perspective and values of the decision maker will affect how, whether, and when they use evidence in their decisions, and how important the evaluation evidence might be against other considerations and pressures.6Kumar MB Taegtmeyer M Madan J et al.How do decision-makers use evidence in community health policy and financing decisions? A qualitative study and conceptual framework in four African countries.Health Policy Plan. 2020; 35: 799-809Crossref PubMed Scopus (10) Google Scholar Third, integrated approaches will respond to complexity in the system-level interventions that are crucial to achieving equity in global health. There is increasing international consensus that global health should shift towards system-level quality improvement interventions for meaningful universal health coverage7Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1152) Google Scholar and to address structural barriers to equity.8Yanful B Kumar MB Elorrio EG Atim C Roder-DeWan S Decolonisation and quality of care.BMJ. 2023; 380e071585PubMed Google Scholar These interventions include service delivery redesign programmes—complex health systems interventions to improve quality codesigned using participatory methods to access local expertise and keep implementation grounded in the reality of seeking and receiving care in each context. There are opportunities for extending this participatory design approach to the economic evaluation to provide results for continuous systems improvement and sustainability.9Roder-DeWan S Madhavan S Subramanian S et al.Service delivery redesign is a process, not a model of care.BMJ. 2023; 380e071651Google Scholar Dynamic human behaviour and multiple feedback loops affect intervention implementation and outcomes, which in turn are shaped by the contextual variations and roles of involved individuals and communities, and need to be centred in evaluations. The figure depicts how integration of participatory and economic approaches in evaluation might capture dimensions that influence the outcomes and sustainability of an intervention. We integrate fundamental components of economic evaluation: inputs or resources required to implement an intervention, and the intervention outcomes, with the mechanisms of achieving those outcomes, the so-called black box, often unknown in economic evaluation.10Kung E Bufali MV Morton A A visual approach to the economic evaluation of vaccines: opening the health economic black box.Expert Rev Pharmacoecon Outcomes Res. 2021; 21: 985-994Crossref PubMed Scopus (0) Google Scholar Elucidating this mechanism can be achieved with the added value of integrating participatory methods throughout the intervention. Deeper understanding of the contextual facilitators and constraints, including those of decision makers and other stakeholders, will provide opportunities to use evaluation results to refine the intervention design, increase ownership and buy-in, and enhance the likelihood of sustainability. Additionally, such an approach can facilitate a deeper understanding of incentives, behaviours, and the costs of non-adoption to address the adaptive nature of complex interventions and systems.11Vassall A Bozzani F Hanson K Considering health-systems constraints in economic evaluation in low- and middle-income settings.Oxford Res Encycl Econ Financ. 2019; (published online June 25.)https://doi.org/10.1093/acrefore/9780190625979.013.38Crossref Google Scholar An integrated approach is likely to enhance an understanding of context and mechanisms as they affect outcomes and inform opportunities to modify interventions for sustainability. The feedback loop highlights a potential for responding to the evaluation findings by improving the intervention (eg, through action research). This dynamic evaluation would link to learnings globally around quality improvement and the fundamental value of patient experiences in the health system.7Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1152) Google Scholar By centring evaluation that considers costs, consequences, and coproduction in complexity as the gold standard in global health, we move closer to centring people in equitable, sustainable, responsive, and accountable health systems. Further development of these methods at the desk and in the field are essential to achieving the future of global health science. We declare no competing interests.